The data sources used for quality improvement measurement, analysis of barriers and determining appropriate interventions include, but are not limited to:
- Claims data
- Utilization review data
- Pharmacy data
- Laboratory data
- Enrollment data
- Behavioral health data
- Medical records
- Appeals data
- Practitioner and member surveys and complaints
- Applicable case management and disease management databases
- Health Outcomes Survey (HOS) data
- Healthcare Effectiveness Data and Information Set (HEDIS®1) data
- Quality Assurance Reporting Requirements (QARR) data
- Consumer Assessment of Healthcare Providers and Systems (CAHPS®2) data
- Quality Compass®3
- National and regional epidemiological, demographic and census data
Integrated data collection systems - such as claims systems, NCQA-approved HEDIS software, credentialing and recredentialing software, etc. - may also be used to collect member, practitioner and provider information; utilization, projects, population based and/or specific member information; and practitioner- and provider-specific information.
1 HEDIS® is a registered trademark of the NCQA.
2 CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
3 Quality Compass® is a registered trademark of the National Committee for Quality Assurance (NCQA).
The Healthcare Effectiveness Data and Information Set (HEDIS®)
HEDIS is a set of performance measures used to assess, compare and report the quality of care that managed care organizations provide. The National Committee for Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality, develops and maintains HEDIS specifications and requires managed care organizations to report HEDIS results annually.
HEDIS technical specifications include general guidelines for data collection, reporting and sampling in measures across five domains of care:
- Effectiveness of care
- Access/availability of care
- Experience of care
- Utilization and relative resource use
- Health plan descriptive information
EmblemHealth requires practitioners to strictly adhere to the NCQA HEDIS guidelines and specifications for all members during each measurement year. EmblemHealth will communicate the HEDIS results to both practitioners and members to encourage the use of preventive services and thus improve healthy outcomes.
NCQA compares HEDIS performance of managed care plans both regionally and nationally in Quality Compass. Summary data and additional information can be found at NCQA's Web site, www.ncqa.org.
Glossary terms found on this page:
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
Conditions that affect thinking and the ability to figure things out that affect perception, mood and behavior.
A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.
An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.
Initial oral or written communication from a member or their designee or provider that expresses discontent with any aspect of their care or coverage with EmblemHealth. Specifically, it is dissatisfaction with:
- A determination made by the plan, other than a determination of medical necessity or a determination that a service is considered experimental or investigational
- Treatment experienced through the plan, its providers or contractors
- Any concern with the plan, its benefits, employees or providers.
An individual person who is the direct or indirect recipient of the services of the organization. Depending on the context, consumers may be identified by different names, such as "member," "enrollee," "beneficiary" or "patient." A consumer relationship may exist even in cases where there is not a direct relationship between the consumer and the organization. For example, if an individual is a member of a health plan that relies on the services of a utilization management organization, then the individual is a consumer of the utilization management organization.
A coordinated system of preventive, diagnostic and therapeutic measures intended to provide cost-effective, quality health care for a patient population who have or are at risk for a specific chronic illness or medical condition.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
Any form of health plan that uses selective provider contracting to have patients seen by a network of contracted providers and that requires prior approval of certain services.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called NCQA.
A nonprofit organization that performs quality-oriented accreditation reviews of HMOs and similar types of managed care plans. Also called National Committee for Quality Assurance.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
The process to objectively and systematically monitor and evaluate the quality, timeliness and appropriateness of covered services, including both clinical and administrative functions, to pursue opportunities to improve health care and resolve identified problems in any of these services.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.